"The trigger for this event was a network configuration change. We will audit our change process and increase the automation to prevent this mistake from happening in the future."
Why they didn't do what? "Increase the automation"? I suspect that they have been doing that from the beginning. It's an ongoing process.
I hate to quote Rumsfeld, but there are known unknowns, and unknown unknowns. Of course you want to eliminate the latter-- but there's (necessarily) no way you can ever know that you've done so.
